Key Points
Question
What is the association of a multiprofessional, preoperative assessment and information day with postoperative complications, length of stay, readmissions, mortality, and costs for patients with head and neck cancer who are undergoing complex oncologic surgery?
Findings
This case-control study that included 161 patients with head and neck cancer found an association between a significantly reduced degree of complication severity, length of hospital stay, and costs and undergoing a multiprofessional preoperative assessment and information day.
Meaning
The study results suggest that a multiprofessional, preoperative assessment and information day for patients with head and neck cancer can potentially reduce the treatment burden and health care charges for patients.
Abstract
Importance
Multidisciplinary perioperative assessment for patients undergoing complex oncologic head and neck cancer (HNC) surgery is widely implemented. However, to our knowledge, the association of multiprofessional preoperative assessment, information, and briefing with postoperative outcomes has not been evaluated.
Objective
To compare postoperative complications, length of hospital stay (LOS), readmissions, mortality, and costs per case among patients undergoing complex oncologic HNC surgery before and after the implementation of a comprehensive preoperative multiprofessional assessment and information day (MUPAID).
Design, Setting, and Participants
This retrospective, single-center case-control study was conducted at a tertiary referral head and neck anticancer center/university cancer institute and compared patients with HNC who were undergoing complex oncological surgeries between January 2012 and July 2018 before (control group) and after (intervention group) implementation of the institutional MUPAID. Data analysis was conducted between 2019 and 2020. The intervention group comprised patients who participated in the MUPAID beginning in February 2015. These patients were assessed by a multiprofessional team and provided with structured and comprehensive information on the surgical procedure and its functional, social, financial, and psychological effects, as well as the postoperative care, rehabilitation, and follow-up period. Patients in the control group had also undergone complex oncologic HNC surgery and were selected through surgical procedure codes.
Main Outcomes and Measures
The end points were postoperative rate and severity of complications, LOS, readmissions, mortality, and costs per case.
Results
The study included 161 patients, 81 in the intervention (25 women [30.9%]) and 80 in the control group (18 women [22.5%]). The groups showed no relevant differences in sociodemographic, disease, and procedural characteristics. The intervention cohort presented with fewer major local and systemic complications (Clavien-Dindo score, III-V: 34.6% vs 52.5%; difference proportion, −0.179; 95% CI, −0.33 to −0.03), shorter median LOS (12 days [IQR, 10-16 days] vs 16 days [IQR, 11-20] days; effect size, 0.482; 95% CI Cohen d, 0.152-0.812) and decreased median charge per case ($50 848 [IQR, $42 510-$63 479] vs $69 602 [IQR, $45 631-$96 280]; effect size, 0.534; 95% CI Cohen d, 0.22-0.85).
Conclusions and Relevance
The results of this case-control study suggest that MUPAID for patients who are undergoing complex oncologic HNC surgery is associated with shortened LOS and costs per case as well as decreased complications severity. These results are promising on a patient level in the potential to minimize individual treatment burden, as well as on an institutional and health care system level in the potential significant optimization of surgical outcomes and financial aspects.
This case-control study compares postoperative complications, length of hospital stay, readmissions, mortality, and costs per case among Swiss patients undergoing complex oncologic head and neck cancer surgery before and after the implementation of a comprehensive preoperative multiprofessional assessment and information day.
Introduction
In 2015, head and neck cancer (HNC) accounted for 932 000 new diagnoses and 370 000 HNC-related deaths worldwide.1,2 Most patients present with advanced-stage disease with a moderate prognosis and an estimated 5-year overall survival (OS) of approximately 50%.3,4,5,6,7
Patients with advanced HNC often require multimodal treatment approaches, including surgery and/or radio(chemo)therapy (RT/CRT). Multimodal therapy carries substantial morbidity, as well as short-term and long-term sequelae, with ensuing functional impairment of breathing, swallowing and speech, and possible disfigurement.7,8,9,10 The rate and severity of postoperative complications, length of hospital stay (LOS), readmissions, and mortality are associated with the complexity of the surgery, but also increase in presence of comorbidities, such as diabetes, cardiovascular disease, hypertension, malnutrition, and smoking.9,11,12,13,14,15 Apart from the physical and psychological implications of such complications and adverse effects, these also lead to higher costs per case.11,16,17,18
Provision of comprehensive information, counseling, and coordinated care by multiprofessional teams may potentially contribute to better postoperative outcomes and care performance in HNC treatment.19,20,21 Previous studies show improved 5-year OS, as well as more efficient and comprehensive care, when multiprofessional approaches are used for patients with HNC who are treated with surgery, RT, CRT, or surgery followed by CRT.22,23,24 For instance, Shenson et al25 reported shorter LOS after preoperative counseling by an HNC surgeon and speech therapist in patients with HNC who were undergoing laryngectomy. However, to our knowledge, the association with postoperative outcomes of multiprofessional assessment and information encompassing medical and nonmedical professionals who are providing comprehensive, preoperative care for patients with HNC who are undergoing complex oncological HNC surgery has not been comprehensively explored.
Today, many cancer centers apply multiprofessional approaches during the perioperative period. However, few centers have adopted comprehensive systematic multiprofessional patient assessment and information before surgery. Based on the past observation that many patients who are undergoing complex oncologic head and neck surgery seemed inadequately prepared despite giving the informed consent provided by the surgeon and are often overwhelmed by the physical and psychological stress inherent to the postoperative period, the Department of Otorhinolaryngology, Head and Neck Surgery at Inselspital, Bern University Hospital and University of Bern (Bern, Switzerland), implemented a structured outpatient multiprofessional preoperative assessment and information day (MUPAID) in 2015. The aim of this day was to provide individualized, structured, and comprehensive information to patients and their families to identify and address individual medical and socioeconomic risk factors. Further, there is potential for the communication and coordination between experts from different professions involved in the management, including advanced nurse practitioners, psychooncologists, speech therapists, social workers, and surgeons to improve. This single-center, before and after implementation case-control study aims to evaluate the association of the MUPAID for patients with HNC who are undergoing complex oncologic surgery with postoperative complications, LOS, readmission rates, mortality rate within 30 days after discharge, and costs per case compared with a control group who did not receive MUPAID.
Methods
Design, Setting, and Population
This single-center, before and after implementation retrospective case-control study was conducted at the Department of Otorhinolaryngology–Head and Neck Surgery at Inselspital, Bern University Hospital, a tertiary referral hospital in Bern, Switzerland. The electronic medical records of patients 18 years or older with HNC who were undergoing complex oncologic surgery (laryngectomy and tumor resections requiring reconstruction with pedicled or free flaps) were retrospectively analyzed. Patients attending MUPAID between February 2015 and July 2018 were prospectively recorded (intervention group). A historical control group, which included patients treated between January 2012 and January 2015, was identified with the help of the hospital central controlling department based on specific codes for the defined complex surgical procedures. Because the introduction of a diagnosis-related groups reimbursement scheme in 2012 was followed by substantial adaptions and optimization of discharge procedures, patients treated before 2012 were not included. The study was conducted in accordance with the ethical guidelines of the 1957 Declaration of Helsinki and approved by the Bernese Cantonal Ethics Committee, and participants provided written informed consent.
MUPAID
The MUPAID is held on a weekly basis. Every patient with HNC for whom complex oncologic surgery was indicated by the internal interdisciplinary tumor board is referred to the MUPAID. This day is based on standardized risk assessment and information packages that were developed by each involved group of professionals based on research evidence and expert knowledge (Table 1). If additional surgical disciplines are involved in the planned surgery, the patient is presented to a surgery board that includes head and neck, maxillofacial, and plastic and reconstructive surgeons at the end of the MUPAID.
Table 1. MUPAID Schedule With Information Provided by Specialized Professionals.
| Professional | Time | Content |
|---|---|---|
| Advanced nurse practitioner | 8:30-9:00 | Welcome and explanation of the schedule |
| Assessment of distress26 | ||
| Resident physician (in presence of a psychooncologist) | 9:00-9:35 | Explains planned operation and related risks |
| Clarifies medical prognosis | ||
| Proposes participation in ongoing studies (if applicable) | ||
| Psychooncologist | 9:45-10:45 | Personal introduction |
| Assessment of psychological burden in patient and relatives | ||
| Information on the psychooncological support services and contact options | ||
| Speech therapist | 11:00-11:30 | Assessment and evaluation of preoperative speech and swallowing function |
| Explanation of postoperative alterations, rehabilitation, and training of speech and swallowing function | ||
| Demonstration of vocal prostheses (if applicable) | ||
| Social worker | 11:30-12:00 | Evaluation of work situation and anticipation of social insurance issues |
| Clarification of housing situation and familial network | ||
| Provision of information leaflets about supportive entities | ||
| Break | ||
| Advanced nurse practitioner | 12:45-13:45 | Comprehensive history including alcohol screening |
| Blood test for preoperative risk screening | ||
| Explanation of postoperative procedures and care during hospital stay (eg, flap monitoring, nonverbal tools for communication) | ||
| Education on management of tracheotomy and feeding tube | ||
| Outpatient clinic nurse | 13:50-14:20 | Assessment of nutritional risk |
| Provision of supplementary preoperative immunonutrition27 | ||
| Multiprofessional team | 14:30-14:45 | Discussion of collected information and interventions to address risk factors |
| Consensus on most appropriate treatment based on comprehensive evaluation of the patient’s situation | ||
| Senior head and neck surgeon | 14:45-15:30 | Detailed discussion of surgery and postoperative procedure, clarification of questions |
| Signing of informed consent form | ||
| Reassessment of distress26 | ||
| Planning of admission date for surgery with patient | ||
Abbreviation: MUPAID, multiprofessional assessment and information day.
Variables and Measurement, Data Sources, and Data Collection
Local and systemic complications were scored either as absent or present. The degree of local and systemic postoperative complications was assessed using the Clavien-Dindo classification system for surgical complications,28 which classifies the complications in 5 grades. Grades I and II are defined as any deviation from the normal or minor complications, while grades III to V represent major complications.29 A local complication was defined as an event requiring pharmacological and/or surgical treatment, such as surgical site infection, wound dehiscence, hemorrhage/hematoma, fistula, seroma, and flap necrosis. Systemic complications followed the same definition for minor and major complications and included events such as pneumonia, urinary tract infection, delirium, refeeding syndrome, cerebrovascular insult, and cardiovascular incident. The LOS was measured from the day of admission (usually the day before surgery) until hospital discharge or transfer to a rehabilitation institution. All readmissions, complications, and deaths occurring during the first 30 days after discharge were recorded.
Costs per case included all case-related costs from hospital admission until discharge following the Swiss standard for hospitals.30 Costs for MUPAID were considered separately, as it is an outpatient intervention and is reimbursed separately by Swiss health insurance companies.31
Other relevant variables, such as age, sex, body mass index (calculated as weight in kilograms divided by height in meters squared), smoking, and alcohol consumption, were extracted from the patient’s electronic medical records. A patient was rated as having comorbidities if 1 or more of the following diseases were diagnosed: diabetes, cardiovascular disease, liver cirrhosis, kidney insufficiency, and current or past cancer diagnosis other than HNC. Because of the retrospective nature of the study, a precise and reliable rating of comorbidities was not possible; therefore, we analyzed the number of the previously mentioned comorbidities with which a patient presented. Localization and tumor stages (UICC TNM Classification of Malignant Tumours,32 7th edition), histopathology, and previous RT/CRT and HNC staging (persistence, relapse or second primary) were recorded. The seventh edition of the UICC TNM classification was used, as this was the version in use at the time of the study. The type of surgery was classified into laryngectomy and other ablative surgery with flap reconstruction. Costs per case were retrieved individually for each patient from the central medical controlling of Inselspital, Bern University Hospital.
Data Analysis
For descriptive statistical analysis, categorical variables were presented as frequency/percentages and continuous variables as mean (SD) or median (IQR), if appropriate. For the comparison of the unpaired group, calculation of the differences in proportions and its confidence interval Wald statistics, differences in the mean independent samples t test with bootstrapping and Cohen d statistics, and differences in the median, the Mann-Whitney U test and Cohen d statistic were used. Outliers (LOS, >30 days) were excluded when calculating the group differences in LOS.
The χ2 test was only applied when counts were sufficient (>5). Distributions of metric variables were tested with Shapiro-Wilk test. Results were considered statistically significant at P < .05. Missing values occurred in the sociodemographic, cancer, and procedural characteristics, but not in the main outcome. Only the variables of smoking and alcohol consumption showed more than 2% of missing values. All statistical tests were 2-sided. Statistical analyses were performed in R, version 3.5.0 (R Foundation)33; SPSS, version 28.0.0.0 (IBM); and Psychometrica (used for the calculation of median difference effect size).34
Results
The study included 161 patients, of which 81 patients (50.3%) were in the intervention group and 80 patients (49.7%) in the historical control group (Figure). Included patients were mostly men (118 [73%]) with advanced-stage disease (UICC TNM 7th edition stage III and IV), and most were smokers (129 [80%]). Comorbidities were present in around 96 patients (59.6%), and the numbers of comorbidities between the groups were not meaningfully different (Table 2). The baseline characteristics of patients did not significantly differ between the groups except for the choice of the type of flap reconstruction (Table 2). Ablative surgery with flap reconstruction was the most common type of surgery, followed by total laryngectomy (Table 2).
Figure. Workflow With Considered, Excluded, and Included Patients.
HNC indicates head and neck cancer; MUPAID, multiprofessional assessment and information day.
Table 2. Sociodemographic, Disease, and Procedural Characteristics for 161 Participants.
| Characteristics | No. (%) | Difference proportions (95% CI)a | |
|---|---|---|---|
| Intervention (n = 81) | Control (n = 80) | ||
| Sex | |||
| Men | 56 (69.1) | 62 (77.5) | −0.084 (−0.22 to 0.06) |
| Women | 25 (30.9) | 18 (22.5) | NA |
| Cancer localization | |||
| Oral cavity | 53 (65.4) | 48 (60.0) | 0.054 (−0.10 to 0.21) |
| Oropharynx | 4 (4.9) | 7 (8.8) | −0.038 (−0.12 to 0.04) |
| Hypopharynx | 1 (1.2) | 4 (5.0) | −0.038 (−0.10 to 0.01) |
| Larynx | 17 (21.0) | 12 (15.0) | 0.06 (−0.07 to 0.18) |
| Other (nasal cavity/paranasal sinus, skin) | 6 (7.4) | 9 (11.3) | −0.038 (−0.13 to 0.06) |
| Squamous cell carcinoma | 74 (91.4) | 71 (88.8) | 0.026 (−0.75 to 0.12) |
| Cancer stage | |||
| Stages III and IV | 60 (74.1) | 54 (67.5) | 0.066 (−0.07 to 0.21) |
| Stages I and II | 21 (25.9) | 26 (32.5) | NA |
| Persistence, relapse, or second primary HNC | 31 (38.3) | 32 (40.0) | 0.017 (−0.13 to 0.17) |
| Previous RT or CRT | 28 (34.6) | 29 (36.3) | −0.017 (−0.18 to 0.12) |
| Smoking, No./No. (%), yes | 57/78 (73.1) | 57/68 (83.8) | −0.102 (−0.24 to 0.04) |
| Alcohol consumption, No./No. (%), yes | 41/76 (53.9) | 43/67 (64.2) | −0.095 (−0.26 to 0.08) |
| Patients with comorbidities | 46 (56.8) | 50 (62.5) | 0.012 (−0.03 to 0.05) |
| 0 Comorbidities | 35 (43.2) | 30 (37.5) | NA |
| 1 Comorbidity | 27 (33.3) | 30 (37.5) | |
| 2 Comorbidities | 8 (9.9) | 16 (20.0) | |
| 3 Comorbidities | 9 (11.1) | 3 (3.8) | |
| 4 Comorbidities | 2 (2.5) | 1 (1.3) | |
| Type of surgery | |||
| Total laryngectomy | 18 (22.2) | 17 (21.3) | 0.010 (−0.12 to 0.13) |
| Ablative surgery with flap reconstruction | 63 (77.8) | 63 (78.8) | NA |
| Surgical reconstruction | |||
| Free flap | 58 (71.6) | 45 (56.3) | 0.154 (0.00 to 0.30) |
| Pedicled flap | 17 (21.0) | 33 (41.3) | −0.203 (−0.34 to −0.07) |
| No flap | 6 (7.4) | 2 (2.5) | 0.049 (−0.02 to 0.12) |
| Tracheotomy | 75 (92.6) | 67 (83.8) | 0.088 (−0.01 to 0.19) |
| Age, mean (SD), yb | 63.7 (11.1) | 63.3 (11.6) | Differences mean, 0.023 (−3.23 to 3.53)c |
| Nutritional status at admission | |||
| BMI, mean (SD)d | 23.75 (3.80) | 24.64 (4.65) | Differences mean, −0.889 (−2.17 to 0.49)c |
Abbreviations: BMI, body mass index (calculated as weight in kilograms divided by height in meters squared); HNC, head and neck cancer; NA, not applicable; RT/CRT, radio(chemo)therapy.
Differences in proportions and 95% CI, calculated with SPSS, version 28.0.0 (IBM), independent-samples proportions tests with bootstrapping, and the Wald statistic.
Effect size (95% CI Cohen d) calculated with SPSS, version 28.0.0 (IBM), and independent-samples t test with bootstrapping.
Difference, mean, and 95% CI, calculated with SPSS, version 28.0.0 (IBM), and independent-samples t test with bootstrapping.
Effect size of −0.21 (95% CI Cohen d, −0.52 to 0.10). Calculated with SPSS, version 28.0.0 (IBM), and independent-samples t test with bootstrapping.
In both groups, 67 patients (intervention group, 84%; control group, 83%) presented with at least 1 local and/or systemic deviation/complication with a Clavien-Dindo grade of I or more. Major complications (grades III-V) requiring surgery or intensive care treatment were present in 42 patients (52.5%) in the control group and in 28 (34.6%) in the MUPAID intervention group (difference proportion, −0.179; 95% CI, −0.33 to −0.03) (Table 3). The most common local complications (intervention group vs control group) were flap dehiscence (17 [22.7%] vs 13 [16.7%]), wound infections (11 [13.6%] vs 14 [17.5%]), and hemorrhage (15 [18.5%] vs 10 [12.5%]). The most commonly documented systemic complications (intervention group vs control group) were refeeding syndrome (38 [46.9%] vs 44 [55.0%]) and respiratory problems (6 [7.4%] vs 18 [22.5%]).
Table 3. Postoperative Local/Systemic Deviations/Complications, LOS, Readmissions, Mortality, and Charges.
| Outcomes | No. (%) | Differencea | Testa | Effect size (95% CI Cohen d)b,c | |
|---|---|---|---|---|---|
| Intervention (n = 81) | Control (n = 80) | ||||
| LOS, median (IQR), d | 12 (10 to 16) | 16 (11 to 20) | Median, 4 | 1848.5 | 0.482 (0.152 to 0.812) |
| Outlier excluded, No. | 77 | 66 | NA | NA | NA |
| LOS initial hospitalization, median (IQR), d | 11 (10 to 16) | 15 (11 to 19) | Median, 4 | 1946.0 | 0.411 (0.082 to 0.74) |
| Charge per case, median (IQR) [range], $ | 50 848 (42 510 to 63 479) [21 654 to 293 000] | 69 602 (45 631 to 96 280) [21 039 to 295 028] | Median, 18 754 | 2272 | 0.534 (0.22 to 0.85) |
| Readmission | 7 (8.64) | 10 (12.5) | Proportion, −0.039b | NA | 95% CI, −0.13 to 0.05b |
| Mortality, deaths | 2 (2.5) | 2 (2.5) | Proportion, 0.00b | NA | 95% CI, −0.05 to 0.05b |
| Deviations/complications | |||||
| Patients with major local and/or systemic complications (Clavien-Dindo grade III-V) | 28 (34.6) | 42 (52.5) | Proportion, −0.179b | NA | 95% CI, −0.33 to −0.03b |
| Patients with ≥1 local deviation/complication | 50 (61.7) | 53 (66.3) | Proportion, −0.045b | NA | 95% CI, −0.19 to 0.11b |
| Patients with ≥1 systemic deviation/complications | 48 (59.3) | 53 (66.3) | Proportion, −0.070b | NA | 95% CI, −0.23 to 0.07b |
| Local deviation/complications total, No. | 70 | 77 | NA | NA | NA |
| Severity of local deviation/complications, highest Clavien-Dindo Score, No. (%) | 50 (61.7) | 53 (66.3) | |||
| Grade I | 19 (23.5) | 8 (10.0) | NA | NA | NA |
| Grade II | 6 (0.4) | 10 (12.5) | |||
| Grade III | 24 (29.6) | 30 (37.5) | |||
| Grade IV | 1 (1.2) | 4 (5.0) | |||
| Grade V | NA | 1 (1.3) | |||
| Systemic deviation/complications total, No. | 64 | 89 | NA | NA | NA |
| Severity of systemic deviation/complications, highest Clavien-Dindo score, No. (%) | 48 (59.3) | 53 (66.3) | |||
| Grade I | 32 (39.5) | 27 (33.8) | NA | NA | NA |
| Grade II | 10 (12.3) | 8 (10.0) | |||
| Grade III | 2 (2.5) | 7 (8.8) | |||
| Grade IV | 2 (2.5) | 10 (12.5) | |||
| Grade V | 2 (2.5) | 1 (1.3) | |||
Abbreviations: LOS, length of stay; NA, not applicable.
Difference median and 95% CI calculated with SPSS, version 28.0.0 (IBM), independent-samples NPar tests, and the Mann-Whitney U test.
Differences in proportions and 95% CI, calculated with SPSS, version 28.0.0 (IBM), independent-samples proportions tests with bootstrapping, and the Wald statistic.
Effect size and 95% CI Cohen d calculated with https://www.psychometrica.de/effektstaerke.html, tests 11 and 1.
On multivariate analysis of factors associated with the development of complications, MUPAID was associated with a nearly 60% reduction (odds ratio, 0.39; 95% CI, 0.19-0.76) in complications compared with the control group. The use of free-flaps was associated with nearly a doubling of complications compared with pedicled flap (Table 4).
Table 4. Multivariate Analysis.
| Variables in the equation | B (SE) | Wald | df | P value | OR (95% CI) |
|---|---|---|---|---|---|
| Step 1a | |||||
| MUPAID | −0.974 (0.354) | 7.569 | 1 | .01 | 0.378 (0.189 to 0.756) |
| Age | 0.001 (0.015) | 0.009 | 1 | .92 | 0.999 (0.969 to 1.029) |
| Sex | 0.189 (0.398) | 0.226 | 1 | .64 | 1.208 (0.554 to 2.633) |
| Advanced stage | 0.444 (0.391) | 1.289 | 1 | .26 | 1.560 (0.724 to 3.359) |
| Flap type | 0.752 (0.402) | 3.509 | 1 | .06 | 2.122 (0.966 to 4.662) |
| Constant | −0.630 (1.113) | 0.321 | 1 | .57 | 0.533 |
Abbreviations: B, logistic regression equation; MUPAID, multiprofessional assessment and information day; OR, odds ratio; Wald, Wald χ2 test; df, degrees of freedom.
Variables entered on step 1: MUPAID (yes, no), age (years), sex (female, male), advanced stage (UICC TNM stage III-IV vs stage I-II), and flap type (free flap, pedicled flap).
The LOS of the initial hospitalization and the complete LOS, including initial hospitalization and readmissions within 30 days after discharge, were shorter in the intervention group, accounting for a median decrease of 4 days compared with the control group. The results remained stable when outlier cases in which total LOS exceeded 30 days were excluded (77 [95.1%], 12 days [IQR, 10-16 days] vs 66 [82.5%], 16 days [IQR, 11-20 days]; effect size, 0.482; 95% CI Cohen d, 0.152-0.812).
Readmission and mortality rates within 30 days after discharge showed no meaningful difference between the 2 groups with 7 patient (8.6%) of the intervention group and 10 (12.5%) of the control group readmitted to the hospital (difference proportion, −0.039%; 95% CI, −0.13 to 0.05) (Table 3). Reasons for readmission in the intervention group were wound infection (2 [28.6%]), flap dehiscence (1 [14.3%]), flap necrosis (1 [14.3%]), dyspnea due to cardiac insufficiency (1 [14.3%]), pneumonia with sepsis (1 [14.3%]), and fall after complicated postoperative course (1 [14.3%]). In the control group, reasons were wound infection (n = 2), bleeding/hematoma (2 [20%]), dyspnea due to tracheostomy management issues (2 [20%]), metabolic issues (2 [20%]), seroma (1 [10%]), and flap necrosis (1 [10%]). Mortality was equal with 2 deaths per group (2.5%). Deaths occurred on the 25th and 30th postoperative days in the intervention group and 15th and 20th postoperative days in the control group.
The median costs per case were reduced by $18 754 in the intervention group compared with the control group (effect size, 0.534; 95% CI Cohen d, 0.22-0.85) (Table 3). Additional charges for the MUPAID ranged from $462 to $1805, depending on the amount of included disciplines in the multiprofessional discussion (average charge of $1176 per MUPAID). Costs for preoperative information of the historical control group could not be retrieved because this process was not coordinated before MUPAID implementation.
Discussion
In this case-control study, we evaluated the association of a MUPAID with outcomes for patients with HNC who were undergoing complex oncologic surgery. The main findings were that the implementation of the MUPAID resulted in (1) less major local and systemic complications (Clavien-Dindo score, III-V: 34.6% vs 52.5%), (2) a meaningful decrease of initial hospital median LOS from 16 (IQR, 11-20) days to 12 (IQR, 10-16) days, and (3) a meaningful reduction in median costs per case from $69 602 (IQR, $45 631-$96 280) to $50 848 (IQR, $42 510-$63 479). To our knowledge, no previous studies reported the association of a preoperative intervention that was comparable with MUPAID with the severity of postoperative complications. Ziegler et al19 showed that comprehensive information on surgery may improve postoperative outcomes as a result of better understanding and therapeutic adhesion. Furthermore, it is well known that patient comorbidities and increased surgical complexity are negatively associated with postoperative performance.35,36 Therefore, the preoperative multiprofessional risk assessment during the MUPAID was fundamental. The medical and social risk factors of patients that are potentially associated with postoperative complications were assessed individually and discussed in the multiprofessional team (Table 1). Based on this comprehensive information, the most appropriate treatment suggestion was made for each patient. Consequently, we could demonstrate a large reduction in the rate of patients with major complications in the MUPAID group.
The rate of deviations/complications was high in both groups compared with other publications.36,37,38,39 However, the applied Clavien-Dindo score included any deviations from the normal postoperative course without pharmacological treatment or surgical, endoscopic, and radiological interventions, with allowed therapeutic regimens such as treatment with antiemetics, antipyretics, analgesics, diuretics, electrolytes, physiotherapy, and opening of wound infections at the bedside (grade I). Grade II complications include pharmacologic treatment (including blood transfusion and parenteral nutrition) with drugs other than those allowed for grade I complications. Therefore, the study’s complication rates may be inflated compared with other studies. Nevertheless, the high complication rate also reflects the burden of coexisting conditions (eg, comorbidities, malnutrition, smoking, alcohol consumption, and previous RT/CRT) and the fact that only complex oncologic surgeries were assessed because MUPAID is resource intensive and therefore accessible only to a highly selected patient population who are at high risk of complications.38
Given the very particular functional impairment and psychosocial consequences associated with complex oncologic HNC surgery and the moderate prognosis of advanced-stage cancer, active involvement of patients in the decision-making process is essential.40,41 The advantage of MUPAID is that patients opting to undergo surgery receive a much clearer idea on what to expect after surgery, and we believe that those patients have better compliance and are psychologically better prepared for the postoperative process and care. However, the increased amount of contact time of the medical team with the patient and the wholistic evaluation of the medical and psychological aspects, as well as the patients’ social environment, allows the medical team to better identify patients who are unsuited for treatment with extensive surgical interventions. Therefore, we hypothesized that along with improved preoperative risk assessment, better patient selection for complex oncologic HNC surgery may in part explain the significant reduction of major complications after MUPAID. Following MUPAID, less-invasive procedures than initially planned were suggested to 2 patients, and another 17 did not undergo surgery at all, mostly because of comorbidities or because the expected functional and aesthetic outcomes were unacceptable for patients when they were comprehensively informed (Figure). This is underlined by the depicted trend of fewer comorbidities in the interventional group. This selection process during MUPAID introduces an intentional selection bias that is inherent to the study design.
This study showed a significant reduction of LOS and costs per case in the group that received MUPAID. Educational interventions, assessment of the social situation, and needs regarding hospital discharge (eg, familial circumstances, housing situation, and organization of rehabilitation) are integral parts of the MUPAID and important factors for an optimization of hospital discharge. With MUPAID, problematic circumstances are identified preoperatively and can be anticipated. Additionally, the reduced rate of major postoperative complications requiring less-invasive interventions and medical treatments also contributed to shorter LOS and reduced charges. This is supported by previous studies, which revealed a strong association between the occurrence of surgical complications, LOS, and costs.18,42,43 Particularly, the need for surgical treatment within 30 days of the primary surgery is independently associated with prolonged LOS.42 Postsurgical complications were associated with a nearly doubled average LOS and an increase in charges of 70% compared with postoperative courses without complications.18 In terms of charges per case, a median reduction of $18 754 USD was identified in patients who participated in the MUPAID. While the average cost of a MUPAID is $1176, the cost of unstructured preoperative treatment of the patients in the historical control group cannot be retrospectively quantified; however, the cost is not free.
The MUPAID was not associated with the rate of readmissions or mortality. Both are comparable with previously reported rates ranging from 3.2% to 26.5%44,45 and 1.0% to 3.05%,44,46,47 respectively. Increased rates of postoperative readmissions have been associated with low socioeconomic status, comorbidities, male sex, advanced disease stage, and complex ablative surgery.15,44 Increased mortality is explained by risk factors such as advanced HNC stage, extensive resections, preoperative dysphagia, higher comorbidity, and advanced age.44,48 Most of these risk factors are nonmodifiable with a preoperative intervention like the MUPAID. Nevertheless, as previously suggested in patients who were undergoing total laryngectomies or required tracheostomy, comprehensive perioperative education has the potential to decrease readmissions because of stomal and tracheoesophageal voice prosthesis management issues.49
Limitations
Because of its retrospective before and after implementation nature and long observational period of 5.5 years, this study has several limitations. Although no obvious changes regarding surgical techniques, composition of the surgical team, or general LOS of patients at our department were identified, time-related aspects could have biased the results, such as increases in surgical skills, changes in multidisciplinary care, or increased system/institution-wide emphasis on decreasing patient costs. While the characteristics of each patient group were very homogeneous, this before and after implementation study design and lack of randomization may have introduced potential confounders that undermine the validity of the study and prevented the ability to make causal inferences from the data. Further, the study population and, in particular, inclusion and exclusion criteria affected the generalizability and transferability of the study results.
Conclusions
The results of this study demonstrate the benefits of systematic and multiprofessional preoperative management in patients undergoing complex oncological HNC surgery. Interventions, such as the presented MUPAID, may help to reduce the severity of complications, LOS, and costs. These results are potentially promising on a patient level in minimizing the individual treatment burden, as well as on an institutional and health care system level by significantly optimizing surgical outcomes and financial aspects. Furthermore, in our experience, the MUPAID fosters a positive relationship between the treating medical team and patients together with their families. Further studies could complement the results of this study from a patient perspective and focus on soft factors, such as stress levels or knowledge gain of patients and their relatives.
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